This post is part of a series of guest posts on GPS by the graduate students in my Psychopathology course. As part of their work for the course, each student had to demonstrate mastery of the skill of “Educating the Public about Mental Health.” To that end, each student has to prepare two 1,000ish word posts on a particular class of mental disorders, with one of those focusing on changes made from the DSM-IV to the DSM-5.
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Splitting Apart Reactive Attachment Disorder in the DSM-5 by Micah Highfill
The new DSM-5 has brought about many changes to classifications of mental disorders. Some changes seem to be long overdue while others leave practitioners confused at what the changes really provide in terms of better diagnosis and treatments. Understanding these changes is important to providing individuals with the most valid and substantiated diagnosis possible, which in turn will hopefully lead to better treatment options as well.
One of the recent changes in organization is to the DSM-IV-TR’s classification of reactive attachment disorder (RAD) by splitting in the DSM-5 to RAD and the new classification of disinhibited social engagement disorder (DSED). RAD was previously defined as either an inhibited type of selective attachments to caregivers or a disinhibited type of selective attachments. The split in the DSM-5 has taken one disorder with two subtypes and changed it into two distinct disorders. By understanding the criterion and other relevant distinguishing characteristics for each of these two disorders and what changed from the previous DSM-IV-TR arrangement, it may provide better clarification of why the change occurred and what benefits may be drawn from the change.
According to the DSM-5, RAD is characterized by emotionally withdrawn behavior in children with a developmental age greater than 9 months and is evident before the age of 5 years. Children with RAD do not seek appropriate selective attachments with caregivers and do not respond appropriately to comfort from caregivers. A persistent social and emotional disturbance is present in the child marked by two of the following three characteristics: minimal social and emotional responsiveness to others, limited positive affect, and episodes of unexplained irritability, sadness, or fearfulness that are evident during nonthreatening interactions with adult caregivers. A pattern of insufficient care must also be present in one of the following ways: social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation, and affection by care giving adults, repeated changes of primary caregivers that limit opportunities to form stable attachments, or rearing in unusual settings that severely limit opportunities to form selective attachments. Frequent changes in foster care placement and institutionalization with limited access to appropriate caregiver interaction are two examples that can lead to the type of insufficient care required for diagnosis. Children with RAD are believed to be able to form selective attachments; however, insufficient opportunity has been presented to this point. Cognitive and developmental delays often co-occur with reactive attachment disorder along with severe malnutrition and depressive symptoms.
The DSM-5 defines DSED as being characterized by a disinhibited display in social interactions and attachments with unfamiliar adults in a child that has a developmental age of at least 9 months. Two of the following behaviors must be present: reduced or absent reticence in approaching and interacting with unfamiliar adults, overly familiar verbal or physical behavior not consistent with culture or age-appropriate social boundaries, diminished or absent checking back with adult caregiver after venturing away, even in unfamiliar settings, or willingness to go off with an unfamiliar adult with minimal or no hesitation. These behaviors must not be limited to impulsivity that could be associated with attention deficit/hyperactivity disorder but rather include socially disinhibited behavior. As with RAD, the same pattern of insufficient care must be present in one of the following: social neglect or deprivation, repeated changes of primary caregivers, or rearing in unusual settings. Unlike typical peers, adolescents with DSED have more peer relationship conflicts and have markedly shallow peer interactions. DSED has not been identified in individuals who have experienced social neglect after 2 years of age. Many children who experience the patterns of insufficient care associated with both disorders do not ever develop either disorder. Both disorders are very rare and the prevalence rate of both disorders is unknown.
The transition of RAD with two subtypes to two distinct disorders has removed the disinhibited type from the criteria previously found in the DSM-IV-TR. This split provides a better classification of symptoms and criteria associated with each disorder by allowing a clearer description of each disorder. The implication for future research, which is greatly needed for two rare disorders, is also greatly benefited by the divide. Limited research exists currently for DSED. Separating the two disorders has made this lack of research more clear than before when disinhibited type was buried in reactive attachment disorder. While a need for more research for both disorders may have been well evident before the DSM-5 changes, the need will likely draw much more attention now. There have been several studies that have shown the distinct nature and course of the two subtypes that led many researchers to believe that the subtypes would be better represented by two different disorders (Gleason et al., 2011). The split could be viewed as a proactive approach to engage researchers in discovering more about two disorders that are currently viewed as disorders with the same precursors but very different behavioral outcomes led by similar diminutive attachment mechanisms.
This split did not include as many small changes in terminology, diagnostic criteria, or symptom expression as many of the other changes to disorders seen throughout the DSM-5, but the transformation of one disorder with two subtypes to two distinct disorders is as bold a change as any other. What we have now are two distinct disorders, which each provide a specific set of criterion as well as other diagnostic features. Without further research to clarify the distinctions and better explain the disorders, we will not know for sure whether the change was warranted and a separate classification is truly necessary. What is known is that the behavioral characteristics of each disorder are very different from each other and to be able to understand more about these differences, why and how they occur, may lead the way to better treatment.
References
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (Fourth Ed. Text Revised). Arlington, VA: American Psychiatric Publishing.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Gleason, M.M., Fox, N.A., Drury, S., Smyke, A., Egger, H.L., Nelson III, C.A., Gregas, M.C., & Zeanah, C.H. (2011). Validity of evidence-derived criteria for reactive attachment disorder: Indiscriminately social/disinhibited and emotionally withdrawn/inhibited types. Journal of the American Academy of Child and Adolescent Psychiatry. 50 (3), pp. 216-231.
